1386616373 NPI number — CHARLES L CONLEY II D.O.

Table of content: CHARLES L CONLEY II D.O. (NPI 1386616373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386616373 NPI number — CHARLES L CONLEY II D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONLEY
Provider First Name:
CHARLES
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386616373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1595
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41105-1595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-408-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRONTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45638-1596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-532-1100
Provider Business Practice Location Address Fax Number:
740-534-0029
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34.007949 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810002365 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71000151330 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2468646 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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